PMS makes the symptoms of BPD worse

Borderline personality disorder

Borderline personality disorder (BPD) (called Emotionally Unstable Personality Disorder, Emotional Intensity Disorder, Borderline Type in the ICD-10) is a cluster B personality disorder whose main characteristics are a pattern of pronounced impulsivity and instability of affects, interpersonal relationships, and self-image . The pattern is present in early adulthood and occurs in a variety of situations and contexts.

Other symptoms can include intense fears of abandonment and intense anger and irritability, the reason others have difficulty understanding. People with BPD are often preoccupied with idealizing and devaluing other people, alternating between high positive esteem and great disappointment. Self-mutilation and suicidal behavior are common.

This disorder is recognized by the Diagnostic and Statistical Manual of Mental Disorders. Because personality disorder is a ubiquitous, persistent, and inflexible pattern of maladaptive internal experiences and pathological behavior, there is a general reluctance to diagnose personality disorders prior to adolescence or early adulthood. However, some emphasize that symptoms can get worse without early treatment.

The terminology of this disorder is constantly debated, especially the word "borderline". The ICD-10 manual calls this disorder Emotional Unstable Personality Disorder and has similar diagnostic criteria. There is concern that the diagnosis of BPD stigmatizes people with BPD and supports discriminatory practices because it suggests that the individual's personality is flawed. The name of the fault remains the same in the DSM-5.

Signs and symptoms

The most pronounced symptoms of BPD are pronounced sensitivity to rejection reactions and thinking about possible abandonment. Overall, the characteristics of BPD are unusually intense sensitivity in relationships with others, difficulty in regulating emotions, and impulsiveness. Other symptoms can include feelings of insecurity about personal identity and values, paranoid thoughts when feeling stressed, and severe dissociation.

Feelings

People with BPD feel emotions more easily, deeply, and longer than others. Emotions can revive again and again and last for a long time. As a result, it may take longer than normal for people with BPD to return to stable emotional baseline after an intense emotional experience.

In Marsha Linehan's view, the sensitivity, intensity, and duration with which people with BPD experience emotions have both positive and negative effects. People with BPD are often extraordinarily idealistic, cheerful, and loving. However, you may feel overwhelmed by negative emotions, experience intense grief instead of grief, shame and humiliation instead of mild embarrassment, anger instead of anger, and panic instead of nervousness. People with BPD are particularly sensitive to feelings of rejection, isolation, and perceived failure. Before learning other coping mechanisms, their efforts to manage or escape their intense negative emotions can lead to self-harm or suicidal behavior. They are often aware of the intensity of their negative emotional reactions and cannot regulate them, so they switch them off altogether. This can be harmful for people with BPD as negative emotions alert people to the presence of a problematic situation and move them to resolve it.

While people with BPD experience joy, they are particularly prone to dysphoria or feelings of mental and emotional distress. Zanarini et al. recognize four categories of dysphoria that are typical of this condition: extreme emotions, destructiveness or self-destruction, feelings of fragmented or lacking identity, and feelings of victimization. Within these categories, a diagnosis of BPD is strongly linked to a combination of three specific conditions: 1) feeling betrayed, 2) feeling like hurting myself, and 3) feeling out of control Types of dysphoria in people with BPD vary widely, the amplitude of the disorder is a helpful indicator of borderline personality disorder.

In addition to intense emotions, people with BPD also experience emotional instability or changeability. Although the term suggests rapid alternation between depression and high spirits, mood swings in people with this condition are actually more likely to be between anger and fear, depression and anxiety.

behavior

Impulsive behaviors are common, including: substance or alcohol abuse, eating disorders, unprotected or indiscriminate sex with multiple partners, reckless spending, and reckless driving. Impulsive behavior can also include quitting jobs or relationships, running away, and self-harm.

People with BPD act impulsively because it provides immediate relief from their emotional pain. In the long run, however, people with BPD will experience increased pain due to the shame and guilt that ensues. A cycle often begins with people with BPD feeling emotional pain, using impulsive behaviors to relieve that pain, feeling shame and guilt about their actions, feeling emotional pain from the shame and guilt, and then experiencing stronger urges, impulsive behaviors to evolve to relieve the new pain. Over time, impulsive behavior can become an automatic response to emotional pain.

Self-harm and suicidal behavior

Self-destructive or suicidal behavior is one of the central diagnostic criteria in the DSM IV-TR. Management and recovery from this behavior can be complex and challenging. The suicide rate in BPD patients is 8 to 10 percent.

Self-harm is common and can occur with or without intent to commit suicide. The reported reasons for non-suicidal self-harm (NSSI) differ from the reasons for attempted suicide. Reasons for NSSI include anger, self-punishment, normal feelings (often in response to dissociation), and distraction from emotional pain or difficult circumstances. Suicide attempts, on the other hand, typically reflect a belief that others are better off after suicide. Both suicidal and non-suicidal self-harm are a response to feeling negative emotions.

Sexual abuse can be a trigger for suicidal behavior, especially in adolescents with BPD tendencies.

Interpersonal relationships

People with BPD can be very sensitive to the way others treat them. They feel intense joy and gratitude for perceived expressions of kindness, and intense sadness or anger for perceived criticism or pain. Their feelings about others often change from positive to negative after disappointment, a perceived threat from the loss of someone, or a perceived loss of appreciation in the eyes of someone they value. This phenomenon, sometimes referred to as division or black and white thinking, involves a shift from idealizing others (feeling admiration and love) to devaluing (feeling anger or dislike). Combined with mood disorders, idealization and devaluation can undermine relationships with family, friends, and colleagues. The self-image can also change quickly from positive to negative.

People with BPD tend to become insecure, evasive, ambivalent in relationships, or develop anxiously worried attachment patterns, and they often view the world as dangerous and vicious. BPD has been linked to increased chronic stress and conflict in romantic relationships, decreased romantic partner satisfaction, abuse, and unwanted pregnancy. However, these factors appear to be related to personality disorders in general.

Manipulation to obtain care is seen by many practitioners of the disease as well as by the DSM-IV as a common characteristic of BPD. However, some mental health professionals warn that overemphasis and too broad a definition of manipulation can lead to misunderstandings and prejudice when treating people with BPD in the healthcare system.

Self-confidence

People with BPD have difficulty getting a clear picture of who they are. In particular, they have a hard time knowing what they value and enjoy. They are often unsure about their long-term goals for relationships and jobs. This difficulty in knowing who they are and what they value can make people with BPD feel "empty" and "lost".

findings

The often intense emotions people with BPD experience can make it difficult for them to focus their attention on concentration. In addition, people with BPD are more likely to dissociate, which can be described as an intense form of "zoning out". Dissociation often occurs in response to a painful event (or in response to something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event, presumably to guard against experiencing intense emotions and unwanted behavioral impulses that might otherwise trigger such emotions. Although the mind's habit of blocking out strong painful emotions can provide temporary relief, it can also have the undesirable side effect of blocking or dulling the experience of common emotions, thereby limiting the access of people with BPD to the information contained in those emotions. that enable effective decision-making in daily life. Sometimes it is possible for another person to tell when someone with BPD is dissociating because their expression on their face or voice becomes flat or expressionless, or they appear distracted; at other times the dissociation is barely noticeable.

diagnosis

The diagnosis of borderline personality disorder is based on a clinical evaluation by a qualified mental health professional. The best method is to present the criteria of the disease to the patient and ask him if he feels that these features describe him or her accurately. Actively involving patients with BPD in the diagnosis can help them increase acceptance. Although some doctors prefer not to tell patients with BPD what their diagnosis is, whether because of concerns about the stigma of the condition or because BPD was previously considered incurable, it is usually helpful for patients with BPD to know their diagnosis . This helps them know that others have had similar experiences and can point them to effective treatments.

The psychological assessment usually includes asking the client about the onset and severity of the symptoms, as well as other questions about how the symptoms affect the client's quality of life. Particularly noteworthy are thoughts of suicide, experiences with self-harm and thoughts about harming others. The diagnosis is based on both the client's report of their symptoms and the doctor's observations. Additional tests for BPD may include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid disease or substance abuse.

Diagnostic and statistics manual

The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) has removed the multi-axis system. As a result, all disorders, including personality disorders, are listed in Section II of the manual. A person must meet 5 out of 9 criteria to be diagnosed with borderline personality disorder. The DSM-5 defines the main characteristics of BPD as a pervasive pattern of instability in interpersonal relationships, self-image and affects, and pronounced impulsive behavior.

In addition, the DSM-5 suggests alternative diagnostic criteria for borderline personality disorders in Section III, "Alternative DSM-5 Model for Personality Disorders". These alternative criteria are based on trait exploration and include the specification of at least four out of seven maladaptive traits.

According to Marsha Linehan, many health professionals find it difficult to diagnose BPD using the DSM criteria because those criteria describe such a wide variety of behaviors. To address this problem, Linehan grouped symptoms of BPD under five main areas of dysregulation: emotions, behavior, interpersonal relationships, self-esteem, and cognition.

International Classification of Diseases

The World Health Organization's ICD-10 defines a disorder that is conceptually similar to borderline personality disorder, referred to as (F60.3) emotionally unstable personality disorder. The two subtypes are described below.

Impulse execution

At least three of the following people must be present, one of whom (2) must be:

  • 1. Distinct tendency towards unexpected and unforeseen action without considering the consequences;
  • 2. Distinct tendency towards contentious behavior and conflict with others, especially when impulsive actions are thwarted or criticized;
  • 3. liability for outbursts of anger or violence, with the inability to control the resulting explosions of behavior;
  • 4. Difficulty maintaining policies that do not offer an immediate reward;
  • 5. unstable and moody (impulsive, moody) mood.

F60.31 frame type

At least three of the symptoms listed in F60.30 must be present, with at least two of the following in addition:

  • 1. Disturbances and uncertainties about self-image, goals and inner preferences;
  • 2. the willingness to enter into intense and unstable relationships that often lead to emotional crises;
  • 3. Excessive efforts to avoid abandonment;
  • 4. Recurring threats or self-harm;
  • 5. Chronic feelings of emptiness.
  • 6. Shows impulsive behavior, e.g. B. Speeding, substance abuse

The ICD-10 also describes some general criteria that define what counts as a personality disorder.

family members

People with BPD are prone to feeling angry with members of their family and alienated from them. For their part, family members often feel angry and helpless about how their BPD family members treat them.

A 2003 study found that family members who knew more about BPD had worse experiences of distress, emotional stress, and hostility towards people with BPD. These results may suggest the need to investigate the quality and accuracy of the information received from family members.

Parents of adults with BPD are often both over and under involved in family interactions. In romantic relationships, BPD is associated with increased chronic stress and conflict, decreased romantic partner satisfaction, abuse, and unwanted pregnancy. However, these links may apply to personality disorders in general.

youth

Onset of symptoms typically occurs in adolescence or young adulthood, although symptoms suggestive of the condition can sometimes be seen in children. Symptoms in adolescents that predict the development of BPD in adulthood can include body image problems, extreme sensitivity to rejection reactions, behavioral problems, non-suicidal self-harm, attempts to find exclusive relationships, and severe shame. Many teens experience these symptoms without developing BPD, but those who experience them are 9 times more likely than their peers to develop BPD. They are also more likely to develop other forms of long-term social disability.

Doctors are discouraged from making a diagnosis before the age of 18, as the result is normal development in adolescence and an even more evolving personality. In this case, the characteristics must have been present and consistent for at least 1 year.

A diagnosis of BPD in adolescence could predict that the disease will persist into adulthood. Among the adolescents who justify a diagnosis of BPD, there appears to be one group where the disease remains stable over time and another group where individuals pull in and out of the diagnosis. Earlier diagnoses can be helpful in creating a more effective treatment plan for teenagers.Family therapy is considered a helpful part of treating adolescents with BPD.

Differential diagnosis and comorbidity

Lifetime comorbid (co-occurring) conditions are common in BPD. Compared to people with other personality disorders who were diagnosed with BPD, people with BPD had a higher rate that also met the criteria for

  • Mood disorders, including major depression and bipolar disorder
  • Anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
  • other personality disorders

Substance abuse

 

  • Eating disorders, including anorexia nervosa and bulimia
  • Attention Deficit Hyperactivity Disorder
  • somatoform disorders
  • dissociative disorders

Axis I comorbid disorders

A 2008 study found that 75 percent of people with BPD meet the criteria for mood disorders, particularly major depression and Bipolar I, and nearly 75 percent meet the criteria for an anxiety disorder at some point in their life. Almost 73 percent meet criteria for substance abuse or addiction, and about 40 percent meet criteria for PTSD. Notably, less than half of the participants with BPD in this study with PTSD reported a prevalence similar to that in a previous study. Finding that less than half of people with BPD will have had PTSD at some point in their lives challenges the theory that PTSD and PTSD are the same condition.

There are marked gender differences in the types of comorbid conditions a person with BPD is likely to have - a higher percentage of men with BPD meet the criteria for substance use disorders, while a higher percentage of women with BPD meet the criteria for PTSD and eating disorders Fulfills. In one study, 38% of participants with BPD met the criteria for a diagnosis of ADHD. In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had significantly more frequent suicide attempts).

Despite the fact that it is an infradiagnosed disorder, some studies have shown that the "lower terms" of it can lead to incorrect diagnoses. The many and changing Axis I disorders in people with BPD can sometimes cause clinicians to miss out on the underlying personality disorder. However, because a complex pattern of Axis I diagnoses has been found to strongly predict the presence of BPD, clinicians can use the feature of a complex pattern of comorbidity as an indication that BPD may be present.

Mood disorders

Many people with borderline personality disorder also have mood disorders, such as: B. major depressive disorder or bipolar disorder. Some features of BPD are similar to mood disorders, which can make it difficult to diagnose. It is especially for people who are misdiagnosed with bipolar disorder if they have borderline personality disorder, or vice versa. For someone with bipolar disorder, behavior suggestive of BPD may occur while the client is experiencing an episode of major depression or mania that does not go away until the client's mood has stabilized. Therefore, it is ideal to wait until the client's mood has stabilized before making a diagnosis.

The affective lability of BPD and the rapid mood cycle of bipolar disorder can basically be very similar. Even for experienced doctors unfamiliar with BPD, it can be difficult to distinguish between the mood swings of these two conditions. There are some noticeable differences, however.

First, the mood swings in BPD and bipolar disorder tend to have mood swings of different lengths. In some people with bipolar disorder, depression or episodes of mania last for at least two weeks, which is much longer than in people with BPD. Even those who experience bipolar disorder with faster mood shifts, their moods typically last for days, while those of people with BPD can change in minutes or hours. While euphoria and impulsiveness might resemble a manic episode in someone with BPD, the experience would be too brief to qualify as a manic episode.

Second, the moods of bipolar disorder do not respond to changes in the environment, while the moods of BPD are responsive to changes in the environment. That is, a positive event wouldn't lift the depressed mood that was caused by bipolar disorder, but a positive event would potentially lift the depressed mood of someone with BPD. Even a negative event wouldn't dampen the euphoria from bipolar disorder, but a negative event would dampen the euphoria of someone with borderline personality disorder.

Third, when people with BPD experience euphoria, it is usually without the frenzied thoughts and decreased need for sleep that are typical of hypomania. And severe, profound sleep disorders are rarely a symptom of BPD, while they are a common symptom of bipolar disorder (along with appetite disorders).

Because the two disorders share a number of similar symptoms, BPD was previously considered a mild form of bipolar disorder or a bipolar disorder on the bipolar spectrum. However, this would require that the underlying mechanism that causes these symptoms be the same for both disorders. Differences in phenomenology, family history, course, and responses to treatment suggest that this is not the case. Researchers have found "only a modest association" between bipolar disorder and borderline personality disorder, with "a strong spectral relationship with [BPD and] bipolar disorder being extremely unlikely". Benazzi et al. suggest that the diagnosis DSM-IV BPD combines two independent features: an affective instability dimension related to bipolar-II and an impulsivity dimension unrelated to bipolar-II.

Premenstrual dysphoria

Premenstrual dysphoria (PMDD) occurs in 3-8 percent of women. Symptoms begin 5-11 days before menstruation and stop a few days after menstruation begins. Symptoms can include: severe mood swings, irritability, depressed mood, desperation or suicide, a subjective feeling of being overwhelmed or overwhelmed, anxiety, eating disorders, difficulty concentrating, and significant impairment in human relationships. Women with PMDD typically begin symptoms in their early twenties, although many women do not seek treatment in their early thirties. Although some of the symptoms of PMDD and BPD are similar, they are different diseases. They differ in the timing and duration of the symptoms, which differ significantly from one another: PMDD symptoms only appear in the luteal phase of a woman's menstrual cycle, BPD symptoms persist in all phases of the menstrual cycle. In addition, the symptoms of PMDD are not impulsive.

Comorbid disorders of axis II

More than two-thirds of people diagnosed with BPD also meet the criteria for another Axis II personality disorder at some point in their life. (In a 2008 study, the rate was 73.9 percent.) Cluster A disorders, which include paranoid, schizoid, and schizotypic disorders, are most common, with a prevalence of 50.4 percent in people with BPD. The second most common are another Cluster B disorder that brings with it antisocial, histrionic, and narcissistic disorders. These have an overall prevalence of 49.2 percent in people with BPD, with narcissistic the most common with 38.9 percent, the second most common with 13.7 percent, histrionic the second most common with 10.3 percent and histrionic with 38.9 percent the most common least common. The rarest are cluster C disorders, which include preventable, dependent, and obsessive-compulsive C disorders and have a prevalence of 29.9 percent in people with BPD. The percentages for specific comorbid Axis II diseases are shown in the table below.

causes

As with other mental disorders, the causes of BPD are complex and not fully understood. There is some evidence that BPD and post-traumatic stress disorder (PTSD) may be linked in some way. Most researchers agree that a history of childhood trauma may be a contributing factor, but less attention has historically been paid to studying the causal roles played by congenital brain disorders, genetics, neurobiological factors, and climatic factors other than trauma.

genetics

The heritable nature of BPD is estimated to be 65%. That is, 65 percent of the variability in symptoms in different people with BPD can be explained by genetic differences. (Note that this is different than when 65 percent of BPD is caused by genes. ”Twin studies can overestimate the impact of genes on variability in personality disorders due to the complicating factor of a shared family environment.

Twin, sibling, and other family studies suggest partial heredity for impulsive aggression, but studies of serotonin-related genes have suggested only modest contributions to behavior.

Brain abnormalities

Hippocampus

The hippocampus is usually smaller in people with BPD than in people with post-traumatic stress disorder (PTSD). In contrast to PTSD, the amygdala is also smaller in BPD.

Amygdala

The amygdala is smaller and more active in people with BPD. Decreased amygdala volume has also been found in people with obsessive-compulsive disorder. One study found unusually high activity in the left amygdalas of people with BPD when experiencing and seeing negative emotions. Because the amygdala is a major structure that evokes negative emotions, this unusually vigorous activity may explain the unusual strength and longevity of fear, sadness, anger, and shame that people with BPD experience, as well as their heightened sensitivity to the portrayal of these emotions in others.

Prefrontal cortex

The prefrontal cortex tends to be less active in people with BPD, especially when it evokes memories of abandonment. This relative inactivity occurs in the right anterior cingulate cingulate (area 24 and 32). Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex could explain the difficulties people with BPD experience in regulating their emotions and responses to stress.

Hypothalamic-pituitary-pituitary-adrenal axis

The hypothalamic-pituitary-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production tends to be increased in people with BPD, indicating a hyperactive HPA axis in these individuals. This leads to a stronger response to biological stress, which could explain their greater susceptibility to irritability. Since traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average HPA axis activity in people with BPD is simply a reflection of the higher than average prevalence of traumatic childhood and maturation events in people with BPD can be. Another possibility is that by increasing their sensitivity to stressful events, increased cortisol production may prepare those with BPD to experience stressful childhood and maturity events as traumatic.

Increased cortisol production is also linked to an increased risk of suicidal behavior.

Neurobiological factors

estrogen

Individual differences in women's estrogen cycles may be due to the expression of BPD symptoms in female patients. A 2003 study found that symptoms of BPD in women were predicted by changes in estrogen levels during their menstrual cycles, an effect that remained significant when the results were controlled for an overall increase in adverse effects.

Symptoms experienced because of impaired levels of estrogen are often misdiagnosed as BPD, such as extreme mood swings and depression. Because endometriosis is an estrogen-dependent disease, severe PMS and PMDD symptoms are observed, which are both physical and psychological in nature. Hormone-dependent mood disorders, also known as reproductive depression, don't stop until after menopause or hysterectomy. Psychotic episodes treated with estrogen in women with BPD show significant improvement, but should not be prescribed to those with endometriosis as it worsens their endocrine condition. Mood-stabilizing drugs for bipolar disorder do not help patients with impaired estrogen levels. A correct diagnosis must be made between endocrine and psychiatric disorders.

Adverse childhood experiences

There is a close relationship between child abuse, especially child sexual abuse, and the development of BPD. Many people with BPD report abuse and neglect as young children. Patients with BPD have found that they are significantly more likely to have been verbally, emotionally, physically, or sexually abused. They also report high incest rates and loss of caregivers in early childhood.

Individuals with BPD were also likely to report having caregivers of both sexes denying the validity of their thoughts and feelings. Caregivers, reportedly, have also failed to provide the necessary protection and neglect the physical care of their child. The parents of both sexes are said to have withdrawn emotionally from the child and treated the child inconsistently. In addition, women with BPD who reported a previous history of female caregiver neglect and male caregiver abuse reported that the likelihood of sexual abuse by a non-caregiver was significantly higher.

It has been suggested that children who experience chronic early mistreatment and attachment difficulties may continue to develop borderline personality disorder.

However, none of these studies provide evidence that childhood trauma is necessarily the cause or the culprit of BPD. Rather, both the trauma and the BPD could be caused by a third factor. For example, many caregivers who have children who are prone to traumatic experiences may be due in part to their own inheritable personality disorders, the genetic predisposition to which they develop their children who develop BPD as a result of this predisposition and other factors previous abuse.

Other development factors

The intensity and reactivity of negative affectivity or the tendency to experience negative emotions are more likely to predict symptoms of BPD than childhood sexual abuse. This finding, the differences in brain structure, and the fact that some patients with BPD do not report a traumatic history suggest that BPD is different from the post-traumatic stress disorder that often accompanies it. In addition to childhood trauma, the researchers are also investigating the causes of development.

Recent research carried out in January 2013 by Dr. Anthony Ruocco at the University of Toronto have highlighted two patterns of brain activity that may underlie the emotional dysregulation indicated in this disorder; Increased activity in the brain circuits responsible for experiencing heightened negative emotions has been described, combined with reduced activation of the brain circuits that normally regulate or suppress these generated negative emotions. These two neural networks are considered to be dysfunctional in the frontolimbic regions, but the individual regions are very different from one another. Also in contrast to previous studies, the patients with BPD showed less activation in the amygdala in situations of heightened negative emotionality than the control group. Dr. John Krystal, Editor of Biological Psychiatry added, "This new report reinforces the impression that people with borderline personality disorders are 'set up' by their brains to lead stormy emotional lives, even if they are not necessarily unhappy or unproductive.

In the psychoanalytic tradition Otto Kernberg writes that the failure of a child in the developmental task of psychological self and foreign body clarification and the failure to overcome division could increase the risk of developing a borderline personality.

A child's inability to tolerate belated gratification by the age of 4 does not predict the later development of BPD.

Communicate and moderate factors

Leadership role

While high sensitivity to rejection reactions is associated with more severe symptoms of borderline personality disorder, executive function appears to mediate the relationship between rejection sensitivity and symptoms of BPD. That is, a group of cognitive processes that include planning, working memory, attention, and problem solving could be the mechanism by which the sensitivity of rejection responses affects BPD symptoms. A 2008 study found that the relationship between a person's sensitivity to rejection reactions and symptoms of BPD was stronger when the managerial role was lower, and that the relationship was weaker when the managerial role was higher. This suggests that high leadership might protect people with high rejection sensitivity from symptoms of BPD.

A 2012 study found that working memory problems could contribute to increased impulsiveness in people with BPD.

Family environment

The family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disease, while a stable family environment predicts a lower risk. One possible explanation is that a stable environment buffers against its development.

Self-complexity

Self-complexity, or considering yourself to have many different characteristics, seems to moderate the relationship between actual self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual traits do not match the traits they are hoping for, high self-complexity reduces the impact of their conflicted self-image on BPD symptoms. However, self-complexity does not diminish the link between actual and actual self-diversity and the development of symptoms of BPD. That is, for individuals who believe that their actual traits do not match the traits they should already have, high self-complexity does not reduce the impact of their conflicting self-image on BPD symptoms. The protective role of self-complexity in actual self-discrepancy, but not in actual self-discrepancy, suggests that the impact of a conflicted or unstable self-image in BPD depends on whether the individual looks at himself in terms of qualities he hopes to have. or in terms of properties it should already have.

Thought suppression

A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediated the relationship between emotional vulnerability and symptoms of BPD. A later study found that the link between emotional vulnerability and BPD symptoms is not necessarily mediated through thought suppression. However, this study found that thought suppression mediates the relationship between an invalidating environment and symptoms of BPD.

treatment

Psychotherapy is the primary treatment for borderline personality disorder. Treatments should be based on the needs of the individual and not on the general diagnosis of BPD. Medications are useful for treating comorbid disorders such as depression and anxiety. Short term hospitalization has not been found to be more effective than community care for improving outcomes or long term prevention of suicidal behavior in those with BPD.

psychotherapy

Long-term psychotherapy is currently the therapy of choice for BPD. There are five treatment options: mentalization-based therapy (MBT), transfer-oriented psychotherapy, dialectical behavior therapy (DBT), general psychiatric care, and schema-focused therapy. While DBT is the therapy that has been most studied, empirical research has shown that all of these treatments are effective for managing BPD, with the exception of scheme-focused therapy. Long-term therapy, including scheme-focused therapy, is better than no treatment, especially when it comes to reducing the urge to self-harm.

Mentalization-based therapy and transfer-oriented psychotherapy are based on psychodynamic principles, while dialectical behavior therapy is based on cognitive behavioral principles and mindfulness. General psychiatric guidance ties the basic principles of each of these treatments together, and it is considered easier to learn and less intense. Randomized controlled studies have shown that DBT and MBT are the most effective method, and they both have a lot in common. The researchers are interested in developing shorter versions of these therapies to improve accessibility, relieve the financial burden on patients, and relieve the burden on treatment providers.

From a psychodynamic point of view, a particular problem in psychotherapy for people with BPD is intense projection. It requires the psychotherapist to be flexible in considering negative assignments from the patient rather than being quick to interpret the projection.

Medication

A 2010 review of the Cochrane collaboration found that no drugs promise "the core symptoms of BPD for chronic emptiness, identity disorders, and abandonment". However, the authors found that some drugs can affect individual symptoms associated with BPD or the symptoms of comorbid conditions.

Of the typical antipsychotics studied in relation to BPD, haloperidol can reduce anger, and flupenthixol can reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, aripiprazole can cause interpersonal problems, impulsiveness, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology. Olanzapine can reduce affective instability, anger, psychotic paranoid symptoms, and anxiety, but a placebo had a greater better effect on suicidal ideations than olanzapine did. The effect of ziprasidone was not significant.

Studied by the mood stabilizers, valproate semisodium may improve depression, interpersonal problems, and anger. Lamotrigine can decrease impulsiveness and anger; Topiramate can relieve interpersonal problems, impulsiveness, anxiety, anger, and general psychiatric pathology. The effect of carbamazepine was not significant. Of the antidepressants, amitriptyline can reduce depression, but mianserin, fluoxetine, fluvoxamine, and phenelzine sulfate had no effect. Omega-3 fatty acids can improve suicidality and relieve depression. The studies with these drugs have not been repeated since 2010 and the effects of long-term use have not yet been assessed.

Because of the weak evidence and the potential for serious side effects from some of these drugs, the UK National Institute for Health and Clinical Excellence (NICE) recommends 2009 clinical guideline for the treatment and management of BPD: "Drug treatment should not be specific to borderline personality disorders or used for individual symptoms or behavior related to the disorder ". "However, drug treatment can be considered in the treatment of comorbid conditions." They propose a "review of treatment for people with borderline personality disorder who have no diagnosed comorbid mental or physical illness and who are currently being prescribed with the aim of reducing and stopping unnecessary drug treatments".

Mindfulness

Over the past two decades, many psychiatrists, psychologists, and other mental health professionals have incorporated mindfulness meditation training into their psychotherapy practice. Mindfulness meditation has been used to help treat or improve the symptoms of disorders such as major depressive disorder, chronic pain, generalized anxiety disorder, and borderline personality disorder, and research has found mindfulness-based therapy to be effective to be especially for reducing anxiety, depression and stress.

Mindfulness meditation has been defined as "paying attention in a certain way: on purpose, in the present moment, and without prejudice".

Services

People with BPD occasionally make extensive use of mental health services. In a survey, they made up about 20 percent of psychiatric hospital stays. The majority of patients with BPD continue to receive outpatient treatment for years, but the number of more restrictive and costly forms of treatment, such as B. inpatient admission, decreases over time. The experience of the services varies. Assessing the risk of suicide can be challenging for clinicians, and patients themselves tend to underestimate the lethality of self-harming behavior. People with BPD usually have a chronically increased risk of suicide well above that of the general public and a history of multiple attempts in times of crisis. About half of all suicides meet the criteria for a personality disorder. Borderline personality disorder remains the most commonly associated personality disorder with suicide.

forecast

With treatment, the majority of people with BPD can find relief from painful symptoms and achieve remission, defined as consistent symptom relief for at least two years. A longitudinal study examining the symptoms of BPD patients found that 34.5% achieved remission within two years of starting the study. 49.4% had achieved remission within four years and 68.6% within six years. At the end of the study, 73.5% of the participants were in remission. In addition, only 5.9% of those affected recovered from the symptoms. A later study found that 86% of patients had permanent and stable recovery from symptoms ten years after the start of the study (while in hospital).

Contrary to popular belief, a cure for BPD is not only possible, but also common for people with the most severe symptoms. However, it is important to note that this high rate of pain relief has only been seen in those treated in some form.

The patient's personality can play an important role during the therapeutic process, which leads to better clinical outcomes. Recent research has shown that BPD patients with higher tolerability of traits who undergo dialectical behavior therapy (DBT) have better clinical outcomes than other patients who either have low agreeability or are not treated with DBT. It should be noted, however, that the primary DBT workbook is people who e.g. B. for the purpose of emotional liberation from fears, advises to draw with red fingernail polish on the arms and after drying with a black felt pen over the dried "blood" (, page 13). DBT has earned its shaky reputation well.

This connection was mediated through the strength of a working partnership between patient and therapist; That is, more pleasant patients developed stronger working alliances with their therapists, which in turn led to better clinical outcomes.

In addition to healing stressful symptoms, BPD patients also achieve a high level of psychosocial functioning. A longitudinal study that looked at the social and professional skills of participants with BPD found that six years after diagnosis, 56% of participants functioned well in work and social settings, compared with 26% of participants when they were first diagnosed were. Work performance was also generally lower compared to other personality disorders. Those whose symptoms were significantly more likely to have good relationships with a romantic partner and at least one parent, good performance at work and school, a sustainable work and school history, and good overall psychosocial functioning.

Epidemiology

The prevalence of BPD is initially estimated to be 1 to 2 percent of the total population and three times more common in women than in men. However, the lifetime prevalence of BPD in a 2008 study was 5.9% of the total population, which occurred in 5.6% of men and 6.2% of women. The difference in rates between men and women in this study was not found to be statistically significant.

Borderline personality disorder is estimated at 20 percent of psychiatric hospital stays and 10 percent of outpatients.

29.5 percent of new inmates in Iowa were diagnosed with borderline personality disorder in 2007, and the overall prevalence of BPD in the US prison population is estimated at 17 percent. These high numbers may be due to the high incidence of substance abuse and substance use disorders among people with BPD, which is estimated at 38 percent.

history

The juxtaposition of intense, divergent moods within an individual was recognized by Homer, Hippocrates and Aretaeus, who most recently described the fluctuating presence of impulsive anger, melancholy and mania within a single person. The concept was revived in 1684 by the Swiss doctor Théophile Bonet, who used the term folie maniaco-mélancolique to describe the phenomenon of unstable moods that followed an unpredictable course. Other authors noted the same pattern, including the American psychiatrist C. Hughes in 1884 and J. C. Rosse in 1890, who called the disease "borderline irritation". In 1921 Kraepelin identified a personality capable of excitability that corresponds closely to the borderline features of today's BPD concept.

The first significant psychoanalytic work with the term "borderline" was written in 1938 by Adolf Stern. It described a group of patients who suffered from what it considered to be a mild form of schizophrenia on the border between neurosis and psychosis.

In the 1960s and 1970s, the trend shifted from imagination to borderline schizophrenia, which was viewed as borderline affective disorder (mood disorder), on the verge of bipolar disorder, cyclothymia, and dysthymia. In the DSM-II, which emphasized the intensity and variability of moods, it was called the cyclothymic personality (affective personality). While the term "borderline" referred to a certain category of disorders, psychoanalysts such as Otto Kernberg used it for a broad spectrum of questions in order to describe a middle level of personality organization between neurosis and psychosis.

After standardized criteria were developed to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis with the publication of the DSM-III in 1980. The diagnosis was distinguished from subsyndromal schizophrenia, which has been termed "schizotypic personality disorder". The DSM-IV Axis II working group of the American Psychiatric Association finally decided on the name "Borderline Personality Disorder", which is still used today by the DSM-IV. However, the term "borderline" is clearly inadequate to describe the disease characteristic symptoms have been described.

Controversy

Credibility and validity of the statement

The credibility of people with personality disorders has been questioned since at least the 1960s. Two concerns are the incidence of dissociative episodes in people with BPD and the belief that lying is a key element of the disease.

dissociation

Researchers disagree on whether dissociation, or the feeling of detachment from emotions and physical experiences, interferes with the ability of people with BPD to remember the specifics of past events. A 1999 study reported that the specificity of autobiographical memory decreased in BPD patients. The researchers found that the decreased ability to remember details was correlated with the patient's degree of dissociation. However, a larger study in 2010 found that people with BPD and without depression had more specific autobiographical memories than people without BPD and with depression.The presence of depression (though not its severity) was the main factor associated with a decreased ability to recall the specifics of past events. This decreased ability was not associated with dissociation and other symptoms of BPD, which supported the reliability of the testimony of people with BPD.

Lies as a feature of BPD

Some theorists argue that patients with BPD often lie. However, others write that in clinical practice they have rarely lied to patients with BPD. Regardless, lying is not a diagnostic criterion for BPD.

Believing that lying is a differentiator of BPD can have an impact on the quality of care people with this diagnosis receive in the legal and healthcare systems. For example, Jean Goodwin relates an anecdote about a patient with multiple personality disorder now called dissociative identity disorder, who suffered from childhood pelvic pain caused by traumatic events. Because of her distrust of her reports of these events, doctors diagnosed her with borderline personality disorder, reflecting a belief that lying is a key element of BPD. Because of her diagnosis of BPD, doctors then disregarded the patient's claim that she was allergic to duct tape. The patient was actually allergic to duct tape, which later led to complications in surgery to relieve her pelvic pain.

gender

Feminists question why women are three times more likely to be diagnosed with BPD than men, while others are stigmatizing diagnoses, such as: An anti-social personality disorder, for example, is three times more likely to be diagnosed in men.

One explanation for this is that some of the diagnostic criteria of BPD perpetuate stereotypes about women. For example, the criteria "a pattern of unstable personal relationships, an unstable self-image and an unstable mood" can be linked to the stereotype that women are "neither decisive nor constant". Women may be more likely to get a personality disorder diagnosis if they reject the traditional feminine role by being assertive, successful, or sexually active. If a woman presents with psychiatric symptoms but does not fit into a traditional, passive sick role, she may be labeled a "difficult" patient and be diagnosed with BPD.

Because BPD is a stigmatizing diagnosis even within mental health care settings, some survivors of child sexual abuse diagnosed with BPD are traumatized again by the negative reactions of health care providers. One camp argues that it would be better to diagnose these women with post-traumatic stress disorder, as this would recognize the effects of the abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society. Regardless, a diagnosis of PTSD does not encompass all aspects of the condition.

Manipulative behavior

Manipulative behavior to achieve perseverance is viewed by the DSM-IV-TR and many psychiatric professionals as a characteristic of borderline personality disorder. Marsha Linehan notes, however, that this is based on the assumption that people with BPD who communicate intense pain or self-harm and suicidal behavior are doing so with the intention of influencing the behavior of others. The effect of such behavior on others - often an intense emotional response from concerned friends, family members, and therapists - is therefore assumed to be the person's intention.

However, because people with BPD are unable to successfully deal with painful emotions and interpersonal challenges, their frequent expressions of severe pain, self-harm, or self-destructive behavior may instead provide a method of mood regulation or an escape mechanism from situations that feel unbearable. Linehan notes that if, for example, burn victims and cancer patients were deprived of pain medication and they were unable to control their severe pain, they would also act "attention-seeking" and self-destructive to deal with it.

Shame

Characteristics of BPD include emotional instability, intense unstable interpersonal relationships, a need for intimacy, and a fear of rejection. People with BPD therefore often evoke intense emotions in their environment. Pejorative terms to describe people with BPD such as "difficult", "treatment-resistant", "manipulative", "demanding" and "alert" are often used and can become a self-fulfilling prophecy as the negative treatment of these people continues triggers self-destructive behavior.

Physical violence

The stigma surrounding borderline personality disorder includes the belief that people with BPD are prone to violence against others. While movies and visual media often make people with BPD sensational by portraying them as violent, most researchers agree that people with BPD have little physical harm to other people. Although people with BPD often struggle with intense anger experiences, a defining characteristic of BPD is that they direct it inwardly on themselves. One of the main differences between BPD and Antisocial Personality Disorder (ASPD) is that people with BPD tend to internalize anger by hurting themselves, while people with ASPD tend to outsource it by hurting others. In addition, adults with BPD have often experienced abuse in childhood, so many people with BPD have a policy of "non-tolerance" to anger of any kind. Their extreme aversion to violence can overcompensate for many people with BPD and create difficulty in being assertive and expressing their needs. This is one way in which people with BPD choose to harm themselves rather than potentially harming others. Another way people with BPD avoid expressing anger through violence is by causing physical harm to themselves, such as causing physical harm to themselves. B. through non-suicidal self-harm.

Mental health care providers

People with BPD are among the most demanding groups of patients to work with in therapy. They require a great deal of skill and training in the psychiatrists, therapists, and nurses involved in their treatment. The majority of mental health workers report that people with BPD are moderately to extremely difficult to work with and more difficult than other client groups. Efforts to improve the attitudes of the public and employees towards people with BPD are ongoing.

In psychoanalytic theory, stigma among psychoanalytic service providers can be viewed as countertransference (when a therapist projects their own feelings onto a client). A diagnosis of BPD "often says more about the doctor's negative reaction to the patient than about the patient" and "explains the collapse of empathy between therapist and patient and, under the guise of pseudoscientific jargon, becomes an institutional nickname". This unintended countertransference can lead to inappropriate clinical responses, including over-medication, inappropriate motherhood, and criminal use of exposure limits and interpretation.

Some clients find the diagnosis helpful because they can understand that they are not alone and connect with others with BPD who have developed helpful coping mechanisms. Others see the term "borderline personality disorder" more as a derogatory label than an informative diagnosis. They report that their self-destructive behavior is mistakenly perceived as manipulative and that the stigma surrounding the condition limits their access to health care. In fact, mental health professionals often refuse to provide services to those who have been diagnosed with BPD.

terminology

Because of the above concerns, and because of a departure from the original theoretical basis for the term, there is an ongoing debate over the renaming of Borderline Personality Disorder. While some clinicians agree with the current name, others argue that it should be changed because many labeled "Borderline Personality Disorder" find the name unhelpful, stigmatizing, or imprecise. Valerie Porr, President of the Association for the Promotion of Treatment and Research Funding for Personality Disorders, explains: "The name BPD is confusing, does not convey any relevant or descriptive information and reinforces existing stigmatization.

Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorders are other valid alternatives, according to John Gunderson of McLean Hospital in the United States. Another term suggested by psychiatrist Carolyn Quadrio is post-traumatic personality disorganization (PTPD), which reflects the status of the disease as (often) both a form of chronic post-traumatic stress disorder (PTSD) and a personality disorder. However, although many people with BPD have traumatic experiences, some do not report traumatic events, suggesting that BPD is not necessarily a trauma spectrum disorder.

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) has unsuccessfully campaigned to change the name and designation of BPD to DSM-5, which was published in May 2013 and in which the name borderline personality disorder remains unchanged remains and is not considered a trauma and stressor-related disorder.

Society and culture

Movie and TV

There are several films that show characters with clearly diagnosed or BPD-like characteristics. Some of these movies could be misleading considering that they depict this disorder. The films Play Misty for Me and Girl, Interrupted, based on the memoir of Susanna Kaysen, with Winona Ryder playing Kaysen both suggest the emotional instability of the disorder, but the first case shows a person being more aggressive towards others than towards himself not characteristic of the disease. Like the first example, the 1992 film Single White Female also suggests features, some of which are actually atypical for the disease: The character Hedy suffers from a clearly disturbed sense of identity and abandonment leads to drastic measures. On HBO's The Sopranos, Dr. Melfi, Tony Soprano's therapist, suggested that his mother suffered from BPD and quoted from the DSM definition of the disease. The characterization definitely shows all properties. Another Lasse Hallström film, What's Eating Gilbert Grape, shows a clear example of the mess in the seductive neighbor Betty (Mary Steenburgen) of Gilbert, (played by Johnny Depp).

Psychiatrists Eric Bui and Rachel Rodgers argue that the character of Anakin Skywalker / Darth Vader in the Star Wars films meets six of the nine diagnostic criteria; Bui also found Anakin to be a useful example for explaining BPD to medical students. In particular, Bui refers to the character's abandonment, uncertainty about his identity, and dissociative episodes. Other films attempting to depict characters with clutter include Deadly Attraction, The Bump, Love Mad, Malevolent Love, Malicious, Interiors, Notes on a Scandal, Cable Guy, Mister Nobody, and Tears.

Unfortunately, dramatic depictions of people with BPD in movies and other visual media add to the stigma of borderline personality disorder, particularly the myth that people with BPD are violent towards others. The majority of researchers agree that, in reality, people with BPD are very unlikely to cause harm to other people.